UC Davis Health System
Clinical Telehealth Program Referral Guidelines
Adult
Nutrition
Clinical Telehealth Consultations
The following is a listing of clinical conditions appropriate for clinical telehealth nutrition consultations. If you
would like to refer a patient with a condition which is not listed below, please send your request with the
patient’s chart notes to the telehealth coordinator for the specialist’s consideration.
Clinical Conditions:
Diabetes (Types I and II, Gestational) - diet & lifestyle only
Hyperlipidemia
Obesity
Post-Bariatric Surgery (> 1 year from surgery)
Polycystic Ovarian Syndrome
Hypertension
Congestive Heart Failure
Food Allergies
GI disease (Pancreatic Insufficiency, Diverticulosis, IBS, IBD,
Celiac Sprue)
Pediatric Nutrition
Malnutrition/Failure to Thrive
Renal disease
Enteral Nutrition
Necessary Clinical Information includes:
Vitals: height, weight and blood pressure
Labs within last 6 months
Consultant: Rachel Perez, MS, RD
Appointment Scheduling:
New: 60 minutes
F/U: 30 minutes
Level of Presenter Required:
No presenter required
Video Equipment Required:
Videoconferencing unit
The following information must be
received prior to scheduling an
appointment:
1. Telehealth Referral Request Form
2. See “Necessary Clinical
Information” in left column
Post Consult Information to have
available for patient:
Patient educational materials
The following must be received
before the consult begins:
1. Signed UCDHS Acknowledgement
of Receipt: Notice of Privacy
Practices form (new patients only)
2. Documented verbal consent from
patient for participation in
telehealth consultation
UCDHS Clinical Telehealth Program
Toll Free: (877) 430-5332
Referral Fax: (866) 622-5944
http://healthsystem.ucdavis.edu/cht/clinic/